Provider Demographics
NPI:1538644471
Name:OUTLAW, DESIREE NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:NICOLE
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:NICOLE
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:22 LIBERTY SQ APT 381
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-5407
Mailing Address - Country:US
Mailing Address - Phone:301-325-6412
Mailing Address - Fax:
Practice Address - Street 1:94 CONNECTICUT BLVD
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3013
Practice Address - Country:US
Practice Address - Phone:860-610-6348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0601291223G0001X
CT12817122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT12817OtherDENTAL LICENSE